WHITE BOOK OF FORMS · 2013-02-15 · MASSACHUSETTS INTERSCHOLASTIC . ATHLETIC ASSOCIATION . WHITE....

MASSACHUSETTS INTERSCHOLASTIC ATHLETIC ASSOCIATION

WHITE BOOK

OF FORMS

For Member School Principals and Athletic Directors

02/07/2013

INTRODUCTION The purpose of this WHITE BOOK is to make available, for reference and duplication, forms currently used by MIAA member schools. The MIAA HANDBOOK explains the appropriate use of each form.

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Table Of Contents – click on page number to access form.

• APPLICATION FOR A COOPERATIVE TEAM ...................................................................................................... 3

• APPLICATION FOR APPROVAL OF MULTIPLE SCHOOL ATHLETIC EVENT* ................................................. 5

• APPLICATION FOR SANCTION OF BORDERING STATE(S) ATHLETIC EVENT.............................................. 6

• GAME EXCLUSION NOTICE ................................................................................................................................. 7

• APPLICATION FOR WAIVER OF BONA FIDE TEAM RULE 45 (AND 96) ........................................................... 8

• APPLICATION FOR WAIVER OF ATHLETIC ELIGIBILITY RULE 53 ................................................................ 10

• AN ELIGIBILITY “CHECKLIST” FOR STUDENTS/PARENTS CONSIDERING TRANSFERRING TO, OR FROM, YOUR SCHOOL ................................................................................................................................................... 12

• MIAA ELIGIBILITY CHECKLIST FOR PRINCIPALS, A.D.’S, & OTHERS ( ) ARE MIAA RULE #’S ................... 13

• TRANSFER RULE ~ FORM 200 ........................................................................................................................ 15

• APPLICATION FOR STUDENT WAIVER OF ATHLETIC ELIGIBILITY RULE ................................................... 16

• PART C: REQUEST FOR STUDENT WAIVER OF THE MIAA TRANSFER RULE ............................................ 18

• STUDENT ELIGIBILITY RULE 52 FORM ............................................................................................................ 19

• ALTERNATIVE, NON-TRADITIONAL EDUCATION RULE #52 (SAMPLE REQUIRED LETTER) ..................... 21

• GROUP COACHES' EDUCATION COURSE REGISTRATION FORM .............................................................. 22

• INDIVIDUAL COACHES' EDUCATION COURSE REGISTRATION FORM ....................................................... 23

• COACH CONTEST DISQUALIFICATION FORM ................................................................................................ 24

• STUDENT CONTEST DISQUALIFICATION FORM ............................................................................................ 25

• (MIAA REFERENCE RULE 49) ............................................................................................................................ 25

• MIAA RECOMMENDED SPORTS CANDIDATE MEDICAL QUESTIONNAIRE ................................................. 26

• RETURN TO ATHLETIC PARTICIPATION.......................................................................................................... 28

• WAIVER OF PHYSICAL EXAMINATION ............................................................................................................. 29

• MIAA – MEDIA AGREEMENT FOR COVERAGE OF TOURNAMENT EVENTS ............................................... 31

• MIAA MEMBER SCHOOL MEDIA WAIVER ........................................................................................................ 33

• TEAM ACADEMIC EXCELLENCE AWARD ........................................................................................................ 34

• MIAA HANDBOOK RULE CHANGE PROPOSAL ............................................................................................... 35

• PROPOSED CHANGE IN LEAGUE AFFILIATION – FORM 1 OF 2 ................................................................... 36

• LEAGUE REALIGNMENT APPLICATION – FORM 2 OF 2 ................................................................................ 37

• *SPORTSMANSHIP HANDSHAKE REPORT FORM .......................................................................................... 39

Massachusetts Interscholastic Athletic Association

Any proposal to form a NEW cooperative team must be in complete form and submitted to the District Athletic Chair at least six months in advance of the beginning practice date for that sport. RENEWALS of existing cooperative teams must be submitted at least three months in advance of the start of the season for that sport.

Application for a Cooperative Team

This form must be completed in detail and must include all pertinent accompanying documentation in one mailing. Please complete one form for each sport, and forward along with accompanying documents to the host school MIAA District Chair. (Please refer to the MIAA website, www.miaa.net, for a list of the current District Chairs.)

PART A DATE:____________________________

1. Names of Cooperating Senior High Schools:

School A: __________________________________________________________________________ School B: __________________________________________________________________________

2. Sport for which the waiver is requested: ___________________________________________________

3. Which school is the host school responsible and accountable for this program?

___________________________________________________________________________________

4. Total School Enrollments (all grades): A: __________ B: _______________

5. High School Enrollments (grades 9-12):

A: Boys __________ Girls ____________ B: Boys ________ Girls ______________

6. Grades included in each high school: A: __________ B: _______________

7. Grades intended to be eligible for this cooperative team: A: __________ B: _______________

(N.B. grade(s) not under the host school principal are not eligible within the cooperating school)

8. Is this a request to renew an already approved cooperative program? Yes ________ No ___________

9. Level and number of student participants in the sport offered the last two years (The most recent year should be recorded/second):

A: Varsity_______/ ______ Junior Varsity________/ _______ Freshman_________/ ________

B: Varsity_______/ ______ Junior Varsity________/ _______ Freshman_________/ ________

10. Kindly describe the “cuts” that were made during the previous two years; i.e. how many students from each

of the cooperating schools had an interest in the sport, but were unable to participate: _______________

___________________________________________________________________________________

___________________________________________________________________________________

Published: July 1, 2001 (continued) Revised 6/21/2007

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11. Kindly indicate the won/loss record for each level sponsored for each of the past two years. __________

___________________________________________________________________________________

12. Number of students anticipated to try out this coming season: A: _________ B: _____________

13. Have you requested, or been approved for, a middle-level waiver? Yes _______ No ___________

If Yes, please identify fully those approved sports. ________________________________________ ___________________________________________________________________________________

PART B

Criteria that must be addressed and submitted with this form. Failure to satisfy any one criterion is sufficient for the request to be denied.

1. A statement expressing the purpose(s) for forming the cooperative team.

2. Minutes of a League meeting including a recorded formal vote inclusive of the support/opposition of each league school. If the team or sport is not league affiliated, then the position of each opponent school regarding the request must be attached.

3. Evidence that this will increase participation numbers.

4. Evidence that previous season participants will not be displaced.

5. Evidence that approval is most unlikely to lead to a dominant team.

6. Evidence that the proposed cooperative team is not motivated by finances.

7. The principal or athletic director of each of the schools involved in an initial request must be present when the District Committee considers that petition.

8. Each of the cooperating schools is expected to submit the per sport service fee at the time of MIAA Membership Renewal each year.

PART C

Safety, insurance, liability, transportation to practices and competitions, etc. are the responsibility of the cooperating schools and outside the responsibility of MIAA and its agents. Resolution of disputes will be through the process established by the cooperating schools; the MIAA will not mediate disputes between the schools.

PART D

The waiver request must be accompanied by supportive signatures of the following: Principal A: ____________________________________ B: _____________________________________ Superintendent A: _______________________________ B: _____________________________________ School Committee Chair A: _______________________ B: _____________________________________ Athletic Director A: ______________________________ B: _____________________________________ Varsity Coach A: ________________________________ B: _____________________________________

4 Revised 6/21/2007Revised 6/21/2007

MIAA TEL: (508) 541-7997 33 Forge Parkway E-mail: [email protected] Franklin, MA 02038 FAX: (508) 541-9888

APPLICATION FOR APPROVAL OF MULTIPLE SCHOOL ATHLETIC EVENT*

THIS APPLICATION MUST BE RECEIVED AT LEAST 45 DAYS PRIOR TO THE SCHEDULED EVENT DATE

All athletic events (tournaments, sport days, scrimmages, jamborees, etc.) involving eight or more schools must have the approval of the MIAA (Handbook Rule 36) with the exception of events that are conducted by, and include only, league members. All events must comply with all MIAA rules and regulations. Applications for events involving out-of-state teams must have the approval of the MIAA and the state associations of the invited schools. Only an MIAA member school may sponsor a multiple-school athletic event.

SECTION 1 - EVENT INFORMATION

EVENT NAME ___________________________________________________________ EVENT DATE ____________________

SPORT _______________________________________ Boys / Girls / Boys & Girls Varsity / Sub-Varsity / Both

SPONSORING SCHOOL ___________________________________________________________________________________

SITE NAME AND ADDRESS: ________________________________________________________________________________

INVITED SCHOOLS: PLEASE PROVIDE A LIST OF ALL INVITED SCHOOLS WITH THIS APPLICATION.

COST AND TYPE(S) OF AWARD(S) ___________________________________________________________________________

ENTRY FEE(S) $ _________________ ADMISSION: Adult $ ______________________ Student $ _____________________

SECTION 2 - EVENT MANAGER

EVENT MANAGER'S NAME _________________________________________________________________________________

EVENT MANAGER'S POSITION _____________________________________________________________________________

EMAIL ___________________________________________ CELL PHONE (________) _________________________________

HOME PHONE (________) __________________________ WORK PHONE (________) ________________________________

SECTION 3 - SPONSORING SCHOOL PRINCIPAL As the sponsoring school principal of this event, I understand that my responsibilities include assuring:

• The event manager is appointed and monitored by one of our school administrators (i.e. principal, assistant principal, athletic director) and will be responsible and present throughout the entire event.

• The event manager and school assumes all responsibility for this event (e.g. enforcement of MIAA Handbook rules, sportsmanship standards, liability, insurance, safety)

• Only Massachusetts schools that are MIAA members and/or out-of-state schools that have been approved by their respective state associations will participate in this event.

• My event manager is, and will be, involved in all aspects of this event including planning, preparation, invitations, event set-up, risk assessment, financial reports (due upon request), etc.

PRINCIPAL'S SIGNATURE ________________________________________________________ DATE __________________

SECTION 4 - OFFICIAL ACTION BY MIAA

OFFICIAL ACTION BY MIAA _________________________________________________________________________________

COMMENTS/LIMITATIONS __________________________________________________________________________________

SIGNATURE OF MIAA OFFICIAL ____________________________________________ DATE ___________________

*Approved by the MIAA Board of Directors (5/4/04) with the unanimous support of the Assembly during the 26th Annual Meeting (4/1/04)

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APPLICATION FOR SANCTION OF BORDERING STATE(S) ATHLETIC EVENT

THIS APPLICATION MUST BE RECEIVED AT LEAST 45 DAYS PRIOR TO THE SCHEDULED EVENT DATE Each school guarantees its membership and good standing in its own state high school association, and that participation in this event will not violate any rule of that association or of the National Federation. Each participant shall be eligible under the rules of his/her state association. Awards shall be limited to such as are permitted by the most restrictive state high school association from which competitors enter. No entry shall be accepted for any competitor from any state or section of a state not included in the list of states for which sanction is granted.

SECTION 1 - EVENT/HOST SCHOOL INFORMATION Host School _________________________________________________________________________________________________ School Address City State Zip Name of event _______________________________________________________ Event Date Sport ___________________________________________ Boys / Girls / Boys & Girls Varsity / Sub-Varsity / Both Site Name and Address ________________________________________________________________________________________ Event Manager _______________________________________________ Position _______________________________________ Email ______________________________________________________ Phone (____ _) ______________________________ Schools invited from the following states: __________________________________________________________________________ Number of invited schools _____________ PLEASE PROVIDE A LIST OF ALL INVITED SCHOOLS WITH THIS APPLICATION Entry Fee __________________________________ Award(s) value and type _________________________________________

As the sponsoring school principal of this event, I understand that my responsibilities include assuring: • The event manager is appointed and monitored by one of our school administrators (i.e. principal, asst. principal, athletic

director) and will be responsible and present throughout the entire event. • The event manager and school assumes all responsibility for this event (e.g. enforcement of MIAA Handbook rules,

sportsmanship standards, liability, insurance, safety) • Only Massachusetts schools that are MIAA members and/or out-of-state schools that have been approved by their

respective state associations will participate in this event. • My event manager is, and will be, involved in all aspects of this event including planning, preparation, invitations, event

set-up, risk assessment, financial reports (due upon request), etc. Sponsoring MIAA Principal: _____________________________________________________________________________________ Signature Date

SECTION 2 - ACTION BY MIAA

State Association Action: Sanction Event Do Not Sanction Event No Jurisdiction Comments/Limitations Signature of MIAA Sanctioning Officer ______________________________________________ Date __________ State ________

SECTION 3 - ACTION BY STATE ASSOCIATION OF INVITED SCHOOL(S)

State Association Membership: Member School Approved School Non-Member School State Association Action: Sanction Event Do Not Sanction Event No Jurisdiction If "No Jurisdiction" please explain why _____________________________________________________________________________ Comments/Limitations _________________________________________________________________________________________ Signature of State Sanctioning Officer _____________________________________________ Date ___________ State _________ After completing Section 3, please forward a copy to the MIAA Office (Fax: 508-541-9888) Revised 5/14/04

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GAME EXCLUSION NOTICE Agreement for the selected schools listed in #2 below

This form must be completed & received in the MIAA office before the first allowable date for

competition in that sport.

Member schools (not listed below) may exceed the maximum number of seasonal competitions by two and exceed the weekly limit by one, when scheduling contests with the schools listed below. Member schools listed below are only allowed to play the maximum number of seasonal competitions and may play each

other, and at least one of the member schools must count the event towards the tournament (if not in the same league).

Please make copies of this form as needed.

Sport ____________________________________ Boys Girls Div: Section: This form need only be executed when you choose not to count, toward tournament qualification and seeding, contests with the schools listed below. Or, if listed school playing another listed school with one opting not to count the contest. Schools listed here & in the same league MUST count all league games.

Since contests do count for these schools, you must also include them on the "MIAA Season Schedule and Commitment Form" you submit to your tournament director on September 30, January 15, or April 15.

1. Your School ____________________________________ 2. Opponent Date(s) Opponent Date(s) Barnstable ________________ Malden HS ___________________

Bishop Feehan(Attleboro) ______________ Martha’s Vineyard ___________________

Bishop Stang(No.Dartmouth) ____________ Medford HS ___________________

Boston College H.S. ________________ Nantucket ___________________

Bridgewater-Raynham ________________ Nauset (No.Eastham) ___________________

Brockton H.S. ________________ New Bedford ___________________

Cambridge R&L ________________ Notre Dame (Hingham) ___________________

Catholic Memorial (W.Rox) _____________ Randolph (’12-13 & ’13-14) ___________________

Coyle & Cassidy (Taunton) _____________ St. John's Prep (D) ___________________

Dartmouth HS ________________ Somerset Berkley Reg ___________________

Durfee HS (Fall River) ________________ Somerville ___________________

Everett HS ________________ Ursuline (Dedham) ___________________

Fontbonne Acad.(Milton) _______________ Xaverian (Westwood) ___________________

Malden Catholic

________________________________________ Date Received Principal or Athletic Director Signature

Revised: 2/7/13

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MIAA TEL: (508) 541-7997 33 Forge Parkway E-Mail: [email protected] FRANKLIN, MA 02038 FAX: (508) 541-9888

APPLICATION FOR WAIVER OF BONA FIDE TEAM RULE 45 (and 96) (To be completed and submitted at least thirty (30) days prior to the event.)

SECTION I 1. Name of Student: 2. Grade: 3. Name of School: 4. School Telephone: 5. City/Town: 6. Zip: 7. Date Submitted:

SECTION II 1. Attach to this form a copy of the invitation received by the student. 2. How many days of school will the student miss? 3. How many practices/games will the student miss?

Games Practices 4. In what sport will the student be participating? 5. What sport will the student be missing by attending that event? 6. Date of the event.

SECTION III Explain your request. By responding to the following points, please give an explanation of your support for the waiver. 1. The name of the event that the student will be attending. 2. Location of the event.

~ (continued)~

Revised 6/14/01

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3. In what way is this event a significant experience? 4. Why is this request supported by the school? ___________________________________________________________ ___________________________________________________________ 5. Endorsement in support of the waiver. Your signature indicates your support of this waiver request:

Principal:

Athletic Director:

Coach:

Parent:

Student:

Revised 6/14/01


Application for Waiver of Athletic Eligibility Rule 53

This form must be completed in detail and include all pertinent accompanying documentation in one mailing. This request will be considered only for inclusion of the entire membership of grade(s) requested. The waiver request must be submitted, minimally 60 days prior to the start of each athletic season (i.e., fall, winter, and spring) to the District Athletic Committee Chair of the petitioning school. If approved, the waiver approval is ONLY for that season and MUST be applied for each school year.

1. Name of Senior High School: __________________________________________________________

2. Current high school grade structure (e.g. 9-12): ___________________________________________

3. High school enrollment (all grades): Boys __________________ Girls ____________________

4. Name of middle school: ______________________________________________________________

5. Current middle school enrollment:

Grade _______ Boys ___________________ Girls ______________________ Grade _______ Boys ___________________ Girls _____________________

Grade _______ Boys ___________________ Girls

6. Grade(s), sport(s) and level(s) for which the waiver is requested: ______________________________

7. Level and number of high school student participants in the sport offered the last two years (The most recent year should be recorded/second):

A: Varsity_______/ ______ Junior Varsity________/ _______ Freshman_________/ ________

B: Varsity_______/ ______ Junior Varsity________/ _______ Freshman_________/ ________

8. Enclose most recent year roster at all levels and by grade in the sport(s) for which you are requesting a

waiver.

9. List by grade the number of students you anticipate will have an interest in participation.

10. Have you requested, or been approved, for a cooperative team? Yes _______ No ____________

If Yes, please identify fully those approved sports. _________________________________________

_________________________________________________________________________________

11. Does your school district offer Middle Level Sport participation? If yes, please list sports: ________

________________________________________________________________________________

Published: July 1, 2001 revised – 8/26/11

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PART B Criteria that must be addressed and submitted with this form:

1. Evidence must be submitted that the rule does not accomplish the purpose for which it was intended. Consideration will not be given if: The request is motivated to provide opportunity for a specific student(s); or, the anticipated high school numbers will support a team.

2. The requested level of athletic participation must be specific and accompany the waiver request.

Consideration will be given for only sub-varsity teams, unless the school offers only a varsity level team. No high school student may be “cut” in favor of a middle school student.

3. It must be stated that there is no middle level participation opportunity for that sport. No approval

will be granted if a middle level opportunity exists in that sport. 4. Minutes of the League Meeting, including a recorded formal vote of support from all league

schools, must be attached to this request. a. A “simple majority” vote is necessary for the request to be advanced to the District Athletic

Committee (DAC). b. The “league” is the group of schools against whom the petitioning school will compete in that

sport. 5. A “simple majority” of a quorum of the DAC is required for approval. 6. The High School Principal is responsible and accountable for adherence to all MIAA and local

standards, and must develop protocols with the Middle School Principal to ensure the integrity of all rules. Further “Supervision” and “Jurisdiction” as defined by MIAA Rule 51 must not be overlooked.

The waiver request must be accompanied by supportive signatures of the following:

Receiving Secondary School Principal ______________________________________________

Sending Middle Level Principal ___________________________________________________

Superintendent of Schools _______________________________________________________

School Committee Chair _________________________________________________________

Athletic Director _______________________________________________________________

Varsity Coach(es) of the Sport Program(s) __________________________________________

revised – 8/26/11

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An Eligibility “Checklist” for Students/Parents Considering Transferring To, or From, Your School

Please read the following if you might participate in interscholastic athletics at your new school. As a transfer student you may not be eligible to represent your new school in athletics.

• A student who transfers from any school to an MIAA member high school is ineligible to participate in any interscholastic athletic contest at any level for a period of one year in all sports in which that student participated at the varsity level or its equivalent during the one year period immediately preceding the transfer.

Exemption to the above :

Change of residence of a student's parents: A student's transfer is necessitated by a change of residence of his/her parent(s) to the area served by the school to which he/she transfers. (This exception does not apply to a change in custody, guardianship, or to a student's change in residence from one parent to another, nor does it apply when the student could continue to attend the former school.)

Additional Eligibility Criteria

• You completed the previous marking period.

• You secured during the last marking period preceding the contest (e.g., second quarter marks and not semester grades determine third quarter eligibility) a passing grade in the equivalent of four major subjects.

To satisfy this requirement, a student must have passed sufficient courses for that marking period which carry

Carnegie Units totaling the equivalent of four traditional 1-year major English courses.

• A student cannot at any time represent a school unless that student is taking courses which would provide Carnegie Units equivalent to four traditional 1-year major English courses.

• To be eligible for the Fall marking period, students are required to have passed for the previous academic year the equivalent of four traditional 1-year major English courses.

• Incomplete grades may not be counted toward eligibility until they are made up following school policy.

• A student who repeats work in which he/she has once received credit cannot count that subject a second time for eligibility.

• A student cannot count for eligibility any subject taken during the summer vacation, unless that subject has been previously pursued and failed during the immediately preceding academic year.

• A student shall be eligible for interscholastic competition for no more than 12 consecutive athletic seasons after first completing the 8th grade.

• A student shall be under 19 years of age, but may compete during the remainder of the school year, provided that his/her birthday occurs on or after September 1 of that year.

• Other MIAA rules also apply.

Revised 8/4/09

MIAA 33 Forge Parkway Franklin, MA 02038

TEL: (508) 541-7997 Email: [email protected] FAX: (508) 541-9888

MIAA ELIGIBILITY CHECKLIST FOR PRINCIPALS, A.D.’s, & OTHERS ( )

ARE MIAA RULE #’s 1. Student Name: _____________________________________________________________ 2. Address:___________________________________________________________________ 3. Age (#60) : _______ Date of Birth: _____________________________________________

a. A student shall be under 19 years of age, but may compete during the remainder of the school year, provided that his/her birthday occurs on or after September 1 of that year.

4. For transferring student only (#57):

a. A student who transfers from any school to an MIAA member HS is ineligible to participate in any interscholastic athletic contest at any level for a period of one year in all sports in which that student participated at the varsity level or its equivalent during the one year period immediately preceding the transfer.

Note: MIAA Form 200 may be executed between the receiving and sending school principals. b. Reason for Transfer:____________________________________________________

(Exemption to the transfer rule: When a student’s school transfer is necessitated (i.e. required) by a change of residence of his/her parent(s) to the area served by the school to which he/she transfers. This exception does not apply to a change in custody, guardianship, or to a student's change in residence from one parent to another, nor does it apply when the student could continue to attend the former school.)

c. A student who participates at the Varsity level at your school, transfers to another school (may or

may not play a Varsity sport), and then returns to your school is ineligible to participate in the varsity sport(s) previously pursued at your school.

5. Date entered school (#51): _____________________________________________________ 6. School enrolled last (#55): _____________________________________________________ 7. Have you ever repeated a grade (#59)? No ___ Yes ______If yes, what grade? __________ a. A student shall be eligible for interscholastic competition for no more than 12 consecutive athletic

seasons after first entering grade 9. 8. Have you ever not attended school on a continuous basis – If yes, when?________________ 9. User Fee ___________________________________________________________________

(continued)

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mailto:[email protected]

10. Grades/transcripts checked (#58) _______________________________________________

a) During the last marking period preceding the contest (e.g., second quarter marks and not semester grades determine third quarter eligibility) a passing grade in the equivalent of four major subjects.

b) To satisfy this requirement, a student must have passed sufficient courses for that marking period which carry Carnegie Units totaling the equivalent of four traditional 1-year major English courses.

c) A student cannot at any time represent a school unless that student is taking courses which would

provide Carnegie Units equivalent to four traditional 1-year major English courses. d) To be eligible for the Fall marking period, students are required to have passed for the previous

academic year the equivalent of four traditional 1-year major English courses.

e) Incomplete grades may not be counted toward eligibility until they are made up following school policy.

f) A student who repeats work in which he/she has once received credit cannot count that subject a

second time for eligibility. g) A student cannot count for eligibility any subject taken during the summer vacation, unless that

subject has been pursued and failed during the preceding academic year.

11. Parent(s) permission form _____________________________________________________ 12. Physical Exam (#56) - Date: ___________________________________________________ 13. For a student to practice with, or to represent a MIAA member school in athletic competition, the student

must be duly enrolled in that school(#51). Also a student shall have been a member of the MIAA member secondary school for a minimum of two months (exclusive of the Summer vacation) and have been issued a report card preceding the contest, unless entering from an elementary or junior high school at the start of the school year or transfers in from another school. (#55.1)

14. Middle School students on Senior High Teams (#53), Home Educated Students (#54), Chemical Health

(#62), Foreign Students (#57.5) & Alternative Programs (#52), all have specific criteria that must be addressed prior to declaring a student eligible.

OTHER MIAA RULES MAY ALSO APPLY. IT IS RECOMMENDED THAT IF YOU HAVE ANY QUESTIONS - CALL THE MIAA (508-541-7997). RULES ARE LISTED IN ( ) FROM THE MIAA HANDBOOK. USE THE ICONS IN THE ON-LINE VERSION FOR FUTHER INFORMATION.

Updated 6/20/11

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THIS FORM MUST BE FULLY EXECUTED PRIOR TO PARTICIPATION - In the case of a student who transfers into your school after the start of that practice season, this form can NOT render approval. You must request a waiver & include Form 200.

TRANSFER RULE ~ FORM 200

A. The Receiving School Principal completes this section and then forwards to the Sending School Principal. 1. Receiving Principal__________________________School_____________________Phone _____________________________ School Fax: ____________________________________________________________________________________________ 2. Student’s Name_______________________________ Grade________ Date of enrollment ______________________________ Student’s Address_________________________________________________ Date of Birth ____________________________ 3. The student wishes to participate in the following sports: Fall: ________________________ Winter: Spring: 4. Student’s reason for transfer: _______________________________________________________________________________

B. The sending School Principal & Athletic Director complete this section & returns to Receiving School Principal.

1. Sending Principal_________________________School_______________________Phone _______________________ 2. List ALL athletic participation since first entering grade 9 (include level of play, e.g.: F, JV, V, AAU, etc. & school)

Grade 9 yr: Grade 10 yr: Grade 11 yr: Grade 12 yr: Fall: School Winter: School Spring: School

3. The Sending School Principal and Athletic Director certify the following by initialing each (complete section 3a-e OR check off box next to section 4):

a. To our knowledge recruitment, was not involved in any way: ________________________________________ b. At the time of transfer, the student was in good standing: ____________________________________________ c. The student would be academically eligible at our school ___________________________________________ d. We have no knowledge that the transfer was related to athletics which would cause our objection to eligibility: _ e. The transfer student would be eligible at our school to participate in athletics: ___________________________ f. Comments: _______________________________________________________________________________

4. (Please DO NOT check this box if you completed #3 above). We support the MIAA Transfer Rule 57.1: A student who

transfers from any school to an MIAA member high school is ineligible to participate in any interscholastic athletic contest at any level for a period of one year in all sports in which that student participated at the varsity level or its equivalent during the one year period immediately preceding the transfer.

5. Has this student had any Chemical Health Violations since the beginning of the Fall Practice Season? No___ Yes____ If yes, please list if penalty: has been served or needs to be served (circle one)

6. Sending School A.D.’s signature:________________________________________ Date ________________________ 7. Sending School Principal’s signature:_____________________________________ Date ________________________

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C. APPROVED (may only be approved when B,3 a through e – ALL have been initialed) 1. The Receiving School Principal certifies (ref. B,3, a-f) Transfer Rule eligibility on: ______/_____/_____ 2. The student also is eligible under all other MIAA and local eligibility standards: ________yes _________no 3. Receiving School Principal’s signature:_____________________________________ Date: _______________________ 4. Receiving School A.D.’s signature:________________________________________ Date _______________________

D. DENIED (must be denied if B,3 a through e – one or more NOT initialed – OR if box next to number 4 is checked) 1. The Receiving School Principal does not certify (ref. B,3, a-e) Transfer Rule eligibility: _____/_____/_____

2. Receiving School Principal’s signature:_____________________________________ Date: ______________________ 3. Receiving School A.D.’s signature:________________________________________ Date _______________________

DO NOT RETURN THIS FORM TO THE MIAA (unless applying for a waiver) PLEASE RETAIN AT THE RECEIVING SCHOOL

Revised 6/20/11

DEADLINES FOR SUBMISSION OF WAIVER REQUESTS: FALL – SEPTEMBER 22 WINTER – DECEMBER 15 SPRING– APRIL1

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TEL: (508) 541-7997 33 Forge Parkway E-mail: [email protected] FRANKLIN, MA 02038 FAX: (508) 541-9888

APPLICATION FOR STUDENT WAIVER OF ATHLETIC ELIGIBILITY RULE

PART A

(To be completed by the PRINCIPAL who is requesting a waiver) District F, Middlesex/MVC, Bay State Conference, and the Tri-Valley League all have been delegated by the MIAA Board of Directors to deal with some student eligibility waivers from their schools and their decisions are final and not reviewable by the MIAA. Waivers approved are for that school year only & may be restricted to one or two seasons depending on the circumstances. Rule Number for which waiver is requested ____________________________ NAME OF STUDENT _______________________________________________________________________________ ADDRESS (Street) _________________________________________________________________________________ CITY/TOWN ________________________________________________ STATE __________ ZIP ___________________ DATE OF BIRTH ________________________ DATE ENTERED PRESENT SCHOOL __________________________ NAME OF SCHOOL REQUESTING WAIVER _____________________ ________SCHOOL TEL ___________________ CITY/TOWN ________________________________________________________________ ZIP ___________________

HIGH SCHOOL RECORD (Please include Grade 9-12)

• Indicate sport and level played (e.g., Freshman, J.V., Varsity, AAU and any non-school sport participation – see Rule 57.2);

• Attach transcript & attendance for every year since first entering Grade 9 until the present; and • Use one line for each school year and/or school.

SCHOOL YEAR

GRADE

SCHOOL WHERE ENROLLED DATES

FALLSPORT

WINTER SPORT

SPRINGSPORT

CREDITS EARNED

~ continued ~ Revised 2/9/11

EXPLAIN YOUR REQUEST: Explain fully what extenuating or unusual circumstances the Association in considering this ineligibility case should know, and please make sure to address any and all other MIAA Rules that would be affected. The four standards that must be addressed at the least are: 85.5.1 The rule works an undue hardship on the student. 85.5.2 Granting the waiver will not result in an unfair competitive advantage. 85.5.3 The waiver approval would not cause displacement of another student-athlete from the

appellant’s own team. 85.5.4 The waiver would not be in conflict with the general well-being of MIAA interscholastic athletic

objectives. (Attach other documents that are required or that seem advisable. If financial hardship is a factor in the

waiver request, please secure from the MIAA the “Support for Financial Consideration” form)

DATE ________________________ PRINCIPAL’S SIGNATURE ____________________________________________________

PART B

To be completed by the STUDENT seeking the waiver and applicant’s parent(s) or guardian(s).

NAME OF PARENT _____________________________________________________________________ ADDRESS (Street) _____________________________________________________________________ CITY/TOWN ________________________________________ STATE _________ ZIP ________________

MIAA meetings are open to the public. However, state law allows for an “executive session” (closed to the public) in cases where private, personal, physical, or medical matters are discussed. Check here if you request executive session consideration of the waiver application. No personally identifiable information in or attached to the student’s application shall be released to anyone other than the staff and reviewing Board/Council members without the specific, informed written consent of the student or parent. We _____________________________________________ , give permission for any and all pertinent (STUDENT AND PARENT) information and attached records related to this athletic eligibility waiver request to be shared with the MIAA Board, Council Members, and Staff who must act upon this request. DATE ________________ SIGNATURE of PARENT ________________________________________ STUDENT ________________________________________

MAIL OR FAX PART A AND B (along with Form 200 if Transfer Rule)

WITH DOCUMENTATION TO: MIAA, 33 Forge Parkway, Franklin MA 02038

FAX: (508) 541-9888 Revised 7/17/06

17

18

MIAA TEL: (508) 541-7997 33 Forge Parkway E-mail: [email protected] FRANKLIN, MA 02038 FAX: (508) 541-9888

PART C: REQUEST FOR STUDENT WAIVER OF THE MIAA TRANSFER RULE

This document must be sent to the PRINCIPAL of the SENDING school

at the time PARTS A and B of the Waiver Request are submitted to the MIAA

Memo to Principal of Sending School: ______________________________________________ PRINCIPAL’S NAME (Print or Type)

______________________________________________ SCHOOL

I am requesting a waiver of the MIAA Transfer Rule on behalf of _____________________________ (NAME of STUDENT)

who wishes to participate in the following sports _________________________________________ at ____________________________________________________________________________ (RECEIVING SCHOOL)

From Principal of Receiving School: _______________________________________________ RECEIVING SCHOOL'S PRINCIPAL'S NAME (Print or Type)

_______________________________________________ RECEIVING SCHOOL'S PRINCIPAL'S SIGNATURE

To Principal of Sending School: Please comment relative to the merits of this request for waiver(i.e. recruitment involved, student in good standing, academically eligible if remained at your school, other). Your information can be very important to the integrity of this process. KINDLY MAIL OR FAX THIS FORM WITH ANY ADDITIONAL INFORMATION SIGNED BY THE PRINCIPAL AND THE ATHLETIC DIRECTOR TO THE MIAA (see above address/fax). ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________

Sending School:

PRINCIPAL’S SIGNATURE

Sending School: ATHLETIC DIRECTOR’S SIGNATURE

Revised 1/20/05

MIAA TEL: (508) 541-7997 33 FORGE PARKWAY E-MAIL: [email protected] FRANKLIN, MA 02038 FAX: (508) 541-9888

STUDENT ELIGIBILITY RULE 52 FORM

This form may be utilized to notify the MIAA of any student declared eligible, by the school principal, to represent a MIAA high school on an interscholastic athletic team as specified in MIAA Rule 52. Students in alternative, collaborative, detached or nontraditional schools (e.g. taking a college course(s), dual enrollment, school to work, work-study etc.) must meet all requirements specified in Rule 52, along with all other high school and MIAA athletic eligibility standards. Check one: _____ Alternative School Placement _____ Collaborative Placement

_____ School to Work Placement _ ____ Work Study Placement

_____ Dual Enrollment _____ Math-Science Academy

_____ Other - Please Specify: __________________________________________

Student’s name:_________________________________________________Grade: ______________ Name of school currently attending: ___________________________________________________ Name of MIAA High School requesting waiver: _____________________________________________ Name of High School previously attended (list school and grades) School granting diploma: ______________________________________________________________ Brief description of program: ___________________________________________________________ __________________________________________________________________________________ Is there an athletic program available in the alternative, detached or other non-traditional program?

YES_____ NO______

If there is an athletic program available, is the student specifically denied access?

Yes___ No___ Please explain: ____________________________________________________

Has a letter of agreement between the MIAA high school principal and the Principal/Director of the alternative site been executed granting the MIAA principal authority to suspend the student from all academic programs? YES____ NO____(include signed letter with waiver request) Does the MIAA high school principal have control and knowledge of the records of the student’s daily attendance and achievement? YES____ NO____

Principal's signature:__________________________________________Date: _________________ (continued)

Revised: 9/14/12

19

52. Student Eligibility: Alternative, Collaborative, Detached or Other Non-Traditional

Educational Programs Students who are not being educated on the high school campus that will issue their diplomas are not eligible to represent that, or any member high school, unless the criteria within this rule are satisfied. If the student is not eligible at the attending college or the alternative institution does not offer any athletic participation opportunity, a student may participate in the diploma-granting MIAA high school if that principal:

• has the authority to suspend the student from all academic programs; and • receives daily reports of the student’s attendance and achievement; and • Certifies the student is eligible by all other MIAA and local standards that must be satisfied

by the student’s teammates. (The above conditions must be agreed to in writing by the non member-school director prior to any practice or athletic participation by the student at the high school that is awarding the diploma.) These non-traditional students may not participate if they do not meet all of the eligibility standards that are required of their teammates. Principals, athletic directors, and guidance personnel should counsel students regarding athletic eligibility prior to committing to non-traditional educational pursuits.

Revised 8/25/08

20

Alternative, Non-traditional Education

Rule #52 (Sample Required Letter)

AGREEMENT ENTERED INTO

BY (MIAA) HIGH SCHOOL AND (NON-MIAA) SCHOOL

REGARDING J. DOE.

As principal of (MIAA) High School, I will be informed in periodic formal reports as to J.

Doe’s attendance and achievement. I will be notified by phone of any absences, and of

academic program changes, by noon on the day they occur. In addition, a formal academic

report will be provided as of the day that marks close for students attending (MIAA) high

school. It is agreed that the (MIAA) High School Principal maintains the authority to

suspend J. Doe from the (non-MIAA) school.

It is further understood that J. Doe is a candidate for a regular (MIAA) High School diploma.

We also certify that there is no athletic participation opportunity available at (non-MIAA)

school.

________________________________ _________________________________

Signature (MIAA) High School of (non-MIAA) School Head Principal

The above agreement addresses requirements within Rule 52 of the MIAA Handbook.

Revised 6/28/05

21

GROUP COACHES' EDUCATION COURSE REGISTRATION FORM

This form should be completed and sent to the MIAA office by coaches' groups who wish to enroll in a MIAA Coaches Education course. Completed forms should be sent to: MIAA Coaches' Education Registration FAX # 508-541-9888 33 Forge Parkway TEL # 508-541-7997 Franklin, MA 02038 Clinic Location ____________________________ Date of Clinic _____________________________ School System _____________________________ School Telephone # _________________________ P. O. # __________________ THE COST OF THE CLINIC IS $95.00 PER COACH CANCELLATION POLICY: Cancellations received up to 72 hours before the clinic will be honored. If you do

not cancel and do not attend, you are responsible for full payment. (Please Print)

Name Phone Sport(s) Email Address

This form may be reproduced as needed. This form should not be sent to any location

other than the MIAA office. Checks or P. O. #'s are required no later than the day of the clinic.

Revised: 9/9/10

22

INDIVIDUAL COACHES' EDUCATION COURSE REGISTRATION FORM

This form should be completed and used by individuals who wish to enroll in a MIAA Coaches' Education course. Completed forms should be sent to:

MIAA Coaches' Education Registration 33 Forge Parkway Franklin, MA 02038

Fax # 508 541-9888 Tel.# 508-541-7997

CANCELLATION POLICY: Cancellations received up to 72 hours before the clinic will be honored. If you do not cancel and do not attend, you are responsible for full payment.

(Please Print)

Name: ___________________________________ _________________________________________ (First) (Last)

Address: ________________________________________________________________________________ # and Street ______________________________________ _______________ _______________________ City/Town State Zip School System: ______________________________________________________________________ Sport(s) you coach ______________________________________________________________________ Telephone # ( )___________________________ ( ) _______________________________ Home Work Email Address: ________________________________________ Location of clinic you wish to attend: _________________________________________________________ Date of clinic you wish to attend: _________________________________________________________ Method of Payment: Purchase Order # _____________ Check # ____________

THE COST OF THE CLINIC IS $95

This form may be reproduced as needed. This form should not be sent to any location other than the MIAA office. Checks or P. O. #'s are required no later than the day of the clinic.

Revised: 9/9/10

23


COACH CONTEST DISQUALIFICATION FORM

(MIAA reference Rule 49) SPECIAL REPORT FROM ATHLETIC OFFICIAL/COACH

All disqualifications must be explained in writing immediately after the contest by the official and coach on separate forms to the Athletic Director and the Principal of the school. There are no exceptions for any coach expelled from a contest. If the game official fails to file his/her report, the coach is still bound by the suspension. He/she must be excluded from the next contest that is part of their regular season schedule or in tournament play. Disqualifications from ice hockey, soccer and baseball are for the next two contests. REPORT FROM ________________________________________________ DATE OF INCIDENT: ______________ PRINT NAME – GAME OFFICIAL or COACH (Circle One) SPORT: __________________________________________________ Boys Girls

LEVEL (check) Varsity Sub-Varsity MIAA Tournament CONTEST BETWEEN __________________________________ and ____________________________________ HOME HIGH SCHOOL VISITING HIGH SCHOOL EXCLUDED COACH: __________________________________ / __________________________________________ NAME SCHOOL SPECIFIC INCIDENT BEING REPORTED (with appropriate explanations included): _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ DATE ____________ SIGNED ________________________________________ POSITION ____________________ PRINT NAME ________________________________________________ PHONE ____________________________

Procedures to be followed:

1. Person in charge of each contest is responsible for having these forms available.

2. At the conclusion of the contest, the official and coach must each complete a separate form and give it to the person in charge of the contest.

3. The person in charge of the contest is responsible for sending both copies within 24 hours of the competition to the:

a. Principal of each school involved b. Athletic Director of each school involved c. Executive Director of MIAA

4. The principal or athletic director of the coach must forward immediately all copies of the official’s and coach’s report to the school superintendent.

Revised 3/30/11

24


STUDENT CONTEST DISQUALIFICATION FORM (MIAA reference Rule 49)

NOTE TO GAME OFFICIALS: All disqualifications must be explained in writing immediately after the contest. Present this completed form to the contest site manager. PROCEDURE TO BE FOLLOWED: (1) The site manager is responsible for having these forms available for officials at the game site. (2) The suspending official shall notify the scorer, the person in charge, and the coach of each team at the time the student is disqualified from a contest for unsportsmanlike conduct. Failure of the official to do so does not exempt a student from the penalty required by the rule. At the conclusion of the contest, the official must complete the form and give it to the site manager. (3) The site manager is responsible for sending copies to the Principal and Athletic Director of each school involved and to the MIAA Executive Director.

Varsity Sub-Varsity Boys Girls MIAA Tournament SPORT ___________________________________ SITE_______________ DATE OF INCIDENT _______________ ______________________________________________ VS. ____________________________________________ HOME TEAM VISITING TEAM SCHOOL OF STUDENT SUSPENDED ________________________________________________________________ SCHOOL CITY/TOWN STUDENT SUSPENDED ___________________________________________________________________________ FIRST LAST NO.

DESCRIPTION OF CIRCUMSTANCES CAUSING DISQUALIFICATION OF THE PLAYER: One form is to be completed for each athlete disqualified. Please describe circumstances causing disqualification from the athlete in the space provided or on reverse side of this form. Violation called: _____________________________ _______________________________________________________________________________________ _______________________________________________________________________________________

(CONTINUE ON OTHER SIDE IF MORE SPACE IS NEEDED)

There are no exceptions for any player disqualified from a contest under Rule 49. He/she must be suspended from the next contest that is part of their regular season schedule or in tournament play (in baseball, ice hockey, and soccer the penalty is two contests) unless it falls under one of the rules below: I. Please check if the violation was for fighting, punching or kicking an opposing player, or spitting at someone a. Rule 49.3.1 (2 game suspension)

II. EACH OF THE FOLLOWING (A AND B) REQUIRES A ONE-YEAR SUSPENSION IN ALL SPORTS. Please check ONLY if this is a violation of:

a. Rule 49.6 (“ . . . physically assaults an official.”)

b. Rule 49.7 (“ . . . willfully, flagrantly, or maliciously attempts to injure an opponent.”)

_______________________________________________________________________________________________ SIGNATURE OF OFFICIAL GIVING PENALTY PLEASE PRINT NAME DATE

Revised 4/25/12

25

MIAA RECOMMENDED SPORTS CANDIDATE MEDICAL QUESTIONNAIRE

PART A ~ HISTORY DATE of EXAM ____________

Student’s Name _________________________________________ Sex ________ Age __________ Date of Birth _____________ Grade _____ School ______________________________________________ Sport(s) ____________________________________ Address _________________________________________________________ Tel ________________________________________ Physician ________________________________________________________ Tel ________________________________________ IN CASE OF AN EMERGENCY, CONTACT: Name Relationship _______________ Tel (H) ____________ (W) ________________

EXPLAIN “YES” ANSWERS BELOW. CIRCLE QUESTIONS YOU DON’T KNOW THE ANSWERS TO.

YES NO 1. Have you had a medical illness or injury ο ο since your last check up or sports physical? 2. Have you ever been hospitalized overnight? ο ο 3. Have you ever had surgery? ο ο 4. Do you have a missing or diseased paired organ? ο ο 5. Are you currently taking any prescription or ο ο nonprescription (over-the-counter) medications or pills or using an inhaler? 6. Have you ever taken any supplements or vitamins ο ο to help you gain or lose weight or improve your performance? 7. Do you have any allergies (for example, to pollen, ο ο medicine, food, or stinging insects)? 8. Have you ever had a rash or hives develop during ο ο or after exercise? 9. Have you ever passed out during or after exercise? ο ο 10. Have you ever been dizzy during or after exercise? ο ο 11. Have you ever had chest pain during or after exercise? ο ο 12. Do you get tired more quickly than your friends do ο ο during exercise? 13. Have you ever had racing of your heart or skipped ο ο heartbeat? 14. Have you had high blood pressure or high cholesterol? ο ο 15. Have you ever been told you have a heart murmur? ο ο 16. Has any family member or relative died of heart ο ο problems or of sudden death before age 50? 17. Have you had a severe viral infection (for example, ο ο myocarditis or mononucleosis) within the last month?

18. Has a physician ever denied or restricted your ο ο participation in sports for any heart problems? 19. Do you have any current skin problems (for example, ο ο itching, rashes, acne, warts, fungus, or blisters)? 20. Have you ever had a head injury or concussion? ο ο 21. Have you ever been knocked out, become ο ο unconscious, or lost your memory? 22. Have you ever had a seizure? ο ο 23. Do you have frequent or severe headaches? ο ο 24. Have you ever had numbness or tingling in your arms, ο ο hands, legs, or feet? 25. Have you ever had a stinger, burner, or pinched nerve? ο ο 26. Have you ever become ill from exercising in the heat? ο ο 27. Do you cough, wheeze, or have trouble breathing ο ο during or after activity? 28. Do you have asthma? ο ο 29. Do you have seasonal allergies that require medical ο ο treatment?

YES NO 30. Do you use any special protective or corrective ο ο equipment or devices that aren’t usually used for your sport or position (for example, knee brace, special neck roll, foot orthotics, retainer on your teeth, hearing aid)? 31. Have you had any problems with your eyes or vision? ο ο 32 Do you wear glasses, contacts, or protective eyewear? ο ο 33. Have you ever had a sprain, strain, or swelling after ο ο injury? 34. Have you broken or fractured any bones or dislocated ο ο any joints? 35. Have you had any other problems with pain or ο ο swelling in muscles, tendons, bones, or joints? If yes, check appropriate box and explain below:

Head Elbow Hip Neck Forearm Thigh Back Wrist Knee Chest Hand Shin/Calf Shoulder Finger Ankle Upper Arm Foot

36. Do you want to weigh more or less than you do now? ο ο 37. Do you lose weight regularly to meet weight ο ο requirements for your sport? 38. Do you feel stressed out? ο ο 39. Record the dates of your most recent immunizations (shots) for: Tetanus ________________ Measles ________________ Hepatitis B ______________ Chickenpox ______________ FEMALES ONLY: 40. When was your first menstrual period? __________________ 41. When was your most recent menstrual period? ___________ 42. How much time do you usually have from the start of one period to the start of another? _________________________ 43. How many periods have you had in the last year? _________ 44. What was the longest time between periods in the last year?

Explain “Yes” answers here: ___________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________

I HEREBY STATE THAT TO THE BEST OF MY KNOWLEDGE, MY ANSWERS TO THE ABOVE QUESTIONS ARE COMPLETE AND CORRECT.

Signature of Athlete/Date _________________________________ Signature of Parent-Guardian/Date _____________________________________

(continued) Revised 8/21/09

PART B ~ PHYSICAL EXAMINATION DATE of EXAM STUDENT (Please print) _______________________________________________ Date of Birth ____________ Height ______ Weight _____ % Body Fat (optional) _____ Pulse ____ BP ______ / ____ ( ____ / ____ , ____ / ___ ) Eyes: R20/ ____________ L20/ __________ Corrected: Y N Pupils: Equal ______ Unequal ______ NORMAL ABNORMAL FINDINGS INITIALS* MEDICAL Appearance Eyes/Ears/Nose/Throat Lymph Nodes Heart Pulses Lungs Abdomen Genitalia (males only) Skin MUSCULOSKELETAL Neck Back Shoulder/Arm Elbow/Forearm Wrist/Hand Hip/Thigh Knee Leg/Ankle Foot *Station-based examination only

PART C ~ CLEARANCE

Cleared

Cleared after completing evaluation/rehabilitation for: __________________________________________________ __________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________

Not cleared for: ______________________________ Reason: __________________________________________ __________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________ DATE of EXAM __________________ Name of physician (Please print): ___________________________________________________________________ Signature of physician: ____________________________________________________ Date: __________________ Address: _______________________________________________________________ Tel: ____________________ Revised 6/14/01

27

THIS FORM IS TO BE FILED AT SCHOOL WITH ORIGINAL INJURY REPORT FORM ~ Please do not return this form to MIAA ~

RETURN TO ATHLETIC PARTICIPATION TO BE COMPLETED BY A SCHOOL OFFICIAL Record No. ________________ 1. STUDENT’S NAME _________________________________ SCHOOL__________________________________ HOME ADDRESS ______________________________________ TEL __________________________________ GRADE ________________________________________ AGE ________________________________________ 2. Injury (illness) information _______________________________________________________________________ Time and date of injury ____________________________ Contest or practice ____________________________ Type of injury _________________________ Sport ____________________ Position played ________________ Coach ____________________________________________ Tel ______________________________________

TO BE COMPLETED BY PHYSICIAN 3. Description of injury ____________________________________________________________________________ ____________________________________________________________________________________________ 4. Referred _____________________________________________________________________________________ Recommendations/restrictions ___________________________________________________________________ a. No restrictions (discharged) as of ____________________________ DATE

I have examined __________________________________________ and certify that he/she is STUDENT recovered from _____________________________________________________________________________ incurred on ________________________________ DATE

b. No practice or competition until _______________________________ DATE

c. Expected return to activity (after further evaluation) ______________________________ DATE

d. Please state restrictions which you require (e.g. no contact, light practice only, etc.) _______________________ e. Other _____________________________________________________________________________________ _____________________________________________ _______________________________________________ PHYSICIAN’S SIGNATURE DATE PARENT’S SIGNATURE DATE

_____________________________________________ ________ COACH’S SIGNATURE DATE STUDENT’S SIGNATURE DATE

Revised 6/14/01

28

WAIVER OF PHYSICAL EXAMINATION

You should be informed that the participation in any contact sport carries with it the risk of serious

physical injury and, in some circumstances, can result in death of an individual. The risks associated

with permanent physical harm or fatalities are increased where pre-existing medical conditions are

present. The Massachusetts Interscholastic Athletic Association, Inc. (hereinafter referred to as “MIAA”)

requires that all students enrolling in any sport should undergo a physical examination by a licensed

medical doctor. This medical examination should be conducted prior to any participation in said sports.

The physical well being of every individual enrolled in any MIAA sponsored sport is the basis for the

organization’s position on this issue.

However, this policy must be interpreted in the light of Massachusetts State Law, which states:

“that any child shall be exempt on religious grounds from these

examinations upon written request of parent or guardian on condition that

the laws and regulations relating to communicable diseases shall not be

violated.” M.G.L. c.71, §57.

Therefore, parent(s) or legal guardian(s) of any student athlete, and in addition, a student athlete who

has attained the age of eighteen (18), should be required to acknowledge the possible risks involved in

waiving a physical examination prior to participation in MIAA sponsored sports, and to submit a written

request prior to any participation in athletics.

It is understood that the MIAA is released and indemnified as to any and all possible liability and shall not

be held liable in any civil action in the case of physical harm, permanent injury, or fatality, of the athlete

resulting from any condition which would have been reasonably foreseeable through a medical

examination.

(continued)

Revised: June 1999 29

ACCEPTANCE OF LEGAL LIABILITY

I/We, ______________________________, and ________________________________, parent(s) or

legal guardian(s) of _______________________________, (hereinafter referred to as the “minor child”)

acknowledge risk inherent in athletic participation and particularly the increased risk existing physical

condition left undetected due to my/our voluntary choice to waive a medical examination, prior to

participation in athletics, could result in serious physical harm or fatality of the minor child or another

participant. However, due to religious beliefs, I/we, ________________________, and

____________________________, acting on behalf of the undersigned minor child, choose to waive the

medical examination required by the Massachusetts Interscholastic Athletic Association, Inc. (hereinafter

referred to as the “MIAA”).

Furthermore, it is agreed that I/we waive liability claims against the MIAA and anyone affiliated with the

MIAA in the event my/our minor child suffers injury or death and indemnify the MIAA, its officers,

employees, officials and coaches, as well as participants in the event, of injury or death to any other

participant. Acting on behalf of the minor child, I/we, ________________________, and

____________________________, parent(s) or legal guardian(s) accept full liability in the event that a

condition that would have been reasonably foreseen through a medical examination results in serious

physical harm or fatal consequences to the minor child while participating in a conditioning or practice

session or in an MIAA sanctioned event or tournament.

Dated: _______________________ Signed: _____________________________________ Parent/Legal Guardian

Dated: _______________________ Signed: _____________________________________ Parent/Legal Guardian

Dated: _______________________ Signed: _____________________________________ Minor Child

Witness: ___________________________________ Witness ____________________________________

30 Revised: June 1999

MIAA – MEDIA AGREEMENT FOR COVERAGE OF TOURNAMENT EVENTS This agreement must be executed and received at the MIAA office 24 hours prior to the event. The rights fee or purchase order number must be presented with this agreement at the tournament site before any recording or broadcasting will be permitted. A copy of this MIAA approved agreement must be presented to the MIAA site manager upon arrival at the tournament site. Terms are defined in the MIAA Media Guide for Tournament Coverage. (Please see over for additional conditions) *Station must provide 1 copy of video for each contest to the MIAA upon request.

EVEN

T

Sport:___________________________________ Div:_______________ Boys Girls

Event:_____________________________Event Date:______________ Site:_____________________

Schools Participating:____________________________vs. ___________________________________

PRO

DU

CIN

G E

NTI

TY

Media Coverage By:___________________________________________________________________ Name of Producing Entity

Address:____________________________________________________________________________ Channel:_____________________________ Date:______________________ Time:______________

ο Broadcast and Regional

ο Delayed Local Cable with Paid Advertising Number of Subscribers__________

ο Delayed Local Cable without Paid Advertisers

ο Radio

ο Live Coverage (Public showing of the event within 20 hours of the completion of the contest)

ο Delayed Coverage (Showing of the event 20 or more hours after the completion of the event)

Program Announcers:__________________________________________________________________

Program Advertisers:__________________________________________________________________

FEES

/ W

AIV

ER

AG

REE

MEN

T The Rights Fee Schedule can be found in the MIAA Media Guide. All conditions prescribed in the “Media Guide for MIAA Tournaments” will be observed by the producing entity.

Fee: $____________ News Fee Waiver: ο NEWS WAIVER: Filming or taping for news purposes is exempt from the rights fee ONLY if no more than three minutes of footage are shown within the context of a regularly scheduled news program.

CO

NTR

AC

T

On behalf of (Station)___________________ I approved this agreement on (Date)______________ Signature:_____________________________ Name Printed:______________________________ Title:_______________________ Fax #:__________________ Phone #:____________________ Subject to further provisions hereof, the MIAA grants to the above named station the rights to broadcast / cablecast the aforementioned sporting event according to the conditions described herein. MIAA Signature:______________________________________ Date:_________________________ (must be signed by MIAA official ONLY for entrance to MIAA tournament events)

MIAA Official Use Only

~ (continued)~ 31

POLICY The Massachusetts Interscholastic Athletic Association (MIAA) owns the broadcast / cablecast rights to each sponsored tournament event. Rights fees are applicable to any public airing of MIAA Tournament Activities unless a written waiver of fees is granted.

PSAs The program must include Association messages approved in advance by the MIAA.

PRODUCING ENTITY The producing entity is defined as the organization or group which is responsible for providing the technical arrangements for recording the event and the means by which the event is broadcast / cablecast to the public. The MIAA recognizes the following types of producing entities:

♦ Broadcast and Regional

♦ Delayed Local Cable with Paid Advertising

♦ Delayed Local Cable without Paid Advertisers

♦ Radio

BROADCAST / CABLECAST SCHEDULE This agreement provides the rights to a public showing of the event on the specified channel.

REPRODUCTION OF THE GAME TAPE Station must provide one copy of video for each contest to the MIAA upon request. No unauthorized duplication or sale of the game tape will be permitted without authorization by the MIAA.

FEES Fees will be assigned to each request based on the nature of the producing entity, the type of broadcast / cablecast, and the prospective audience. The signed contract along with a check or purchase order number covering the fee must be presented at the tournament site before the radio / TV / cable station will be allowed to set up.

CONTRACT AGREEMENT The contract can be executed by faxing the completed application form to the MIAA office for the appropriate signature. The MIAA reserves the right to refuse any request.

Massachusetts Interscholastic Athletic Association, Inc. 33 Forge Parkway ~ Franklin, MA 02038

Phone: 508-541-7997 ~ Fax: 508-541-9888 www.miaa.net ~ e-mail: [email protected]

Revised: October 2007

32

MIAA MEMBER SCHOOL MEDIA WAIVER

SPORT: DIV: BOYS or GIRLS ____ EVENT: DATE: SITE: ______ SCHOOLS: ______________VS.____________________________________ SCHOOL WAIVER: Taping for community access cable by member school students who were involved in the exercise for educational purposes during the school’s regular season contests. Early in the program, this statement will be included in the program: “The rights fee to this cablecast has been waived by the MIAA on behalf of the students of _____________________________ High School. The “MI double A” represents 368 senior high schools across the Commonwealth and the more than 200,000 young men and women who participate annually in “MI double A” governed athletic competition. Any re-broadcast or re-publication of this program without the written consent of the MIAA is prohibited. * Throughout the program, the station will include eight (8) different MIAA spots (samples may be found in the

MIAA Media Guide.) * The school principal agrees that the program will not expose negative or questionable activity which may occur

during the event (e.g. fights, crowd reactions, etc.) * The station assumes the responsibility for arrangements with the facility management and assumes all related

expense. * The station agrees to provide insurance coverage for bodily and personal injury, property damage, and liability

including coverage for libel, slander, defamation, copyright infringement, piracy, or unfair competition and invasion of privacy.

This agreement also takes into consideration and covers the following situations: COACHING WAIVER: Filming or taping strictly for coaches’ use will be considered provided the agreement is properly executed and approved by the member school principal. SCHOOL VIDEO YEARBOOK: Filming or taping strictly for this use will be considered provided the agreement is properly executed and approved by the member school principal.

In case of a school waiver, the MIAA site manager must be informed at least 24 hours in advance of the school's intent to tape the event for a future cablecast. Taping of the event by member school students for community access cable is allowed when students have been involved in the taping of regular season activities and are involved during the tournament production in a meaningful way for educational purposes. The tape will not be reproduced or sold, and will be aired outside the school building only ONCE on the local community access channel which is limited to the community served by the high school.

NAME AND GRADE OF EACH STUDENT:

___________________________________________________ ________________________________________ ___________________________________________________ ________________________________________ Students' Supervisor (Signature) ___________________ (Print) _________________________________________ Station Manager (Signature) ______________________ (Print) _________________________________________ Principal (Signature) ____________________________ (Print) _________________________________________

Faxing this form to the MIAA is not required.

Final authorization rests with the member-school principal. Revised: May 1999

33


TEAM ACADEMIC EXCELLENCE AWARD

To encourage and support the academic accomplishments of student-athletes, the Board of Directors is sponsoring the Team Academic Excellence Award. The Association will recognize all members of teams that maintain a combined grade point average (GPA) of 2.5 and above. There will be two award categories for which teams will be eligible for recognition:

GOLD LEVEL 3.00 to 4.00 (Please compute grade point SILVER LEVEL 2.50 to 2.99 averages to three places.)

This team concept toward academic achievement should be an incentive for all team members to raise their individual GPA, thereby positively affecting their team’s average. This program will provide an excellent opportunity for coaches to discuss academic achievement with their student-athletes on a regular basis. Each team member and the school will receive recognition.

KINDLY NOTE THE FOLLOWING: 1. All teams are eligible – e.g. freshmen, junior varsity, varsity 2. Team managers, statisticians, etc., may be included 3. For each marking period, teams eligible are those currently in season on the date that the marks close.

I, _____________________________________ , Principal of _______________________________ High School, request that the below listed team(s) be recognized for outstanding academic achievement. Each has fulfilled the criteria as listed above.

SPORT B/G LEVEL (F, JV, V) GPA NO. OF TEAM MEMBERS 1. ___________________________ ________ ___________________ __________ _______________ 2. ___________________________ ________ ___________________ __________ _______________ 3. ___________________________ ________ ___________________ __________ _______________ 4. ___________________________ ________ ___________________ __________ _______________ 5. ___________________________ ________ ___________________ __________ _______________ CITIZENSHIP

In addition to academic excellence, each above-named team has exhibited outstanding citizenship and sportsmanship throughout this season.

SPORT COACHES’ SIGNATURES 1. ___________________________________________________ ________________________________________________________ 2. ___________________________________________________ ________________________________________________________ 3. ___________________________________________________ ________________________________________________________ 4. ___________________________________________________ ________________________________________________________ 5. ___________________________________________________ ________________________________________________________ _______________________________________ __________________________________________________________ DATE OF APPLICATION SIGNATURE OF PRINCIPAL __________________________________________________________ SIGNATURE OF ATHLETIC DIRECTOR Revised 6/14/01

34


MIAA HANDBOOK RULE CHANGE PROPOSAL

MUST BE RECEIVED AT THE MIAA OFFICE ON OR BEFORE JUNE 1, 2014 Please fax, mail, or email

AREA OF RULE PROPOSAL (check Table of Content for correct Part) ________________________________________ PAGE _________________________________ RULE NUMBER __________________________________ SUBMITTED BY/DATE _____________________________________________________________________________ NAME TITLE DATE

___________________________________________________________________________________ SCHOOL OR HOME ADDRESS

___________________________________________________________________________________ TOWN ZIP TELEPHONE EMAIL

PROPOSAL (Exactly as you want it to appear in the MIAA Handbook – Continue on additional sheet if needed): _______ ________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________ RATIONALE (Reason proposal should replace or be added to existing rule, or why need a new rule): ________________

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

OTHER RULES AFFECTED Page_________________Rule #_________________How____________________________________________________________ Page_________________Rule #_________________How____________________________________________________________ Page_________________Rule #_________________How____________________________________________________________

Published: July 1, 2003 revised 6/11/12

35


Proposed Change in League Affiliation – Form 1 of 2

To be completed by the Principal of any school who is considering changing the status quo of any League. Note: This form should be completed and forwarded to the MIAA Executive Director who will then initiate the process that should be completed by any school seeking a change in the structure of any league. A. Name of School: ________________________________________________________ B. Current League Affiliation (if any): ___________________________________________ League President: _______________________________________________________ League Secretary: _______________________________________________________ C. Desired Future League Membership: _________________________________________ League President: ________________________________________________________ League Secretary: ________________________________________________________ D. Desired Academic Year of Realignment _______________________________________ 3/10/2006

36

League Realignment Application – Form 2 of 2

(Reference MIAA Rule #42)

Procedure for Submission of Realignment Proposal

To be submitted to the MIAA District Chair two years in advance of the requested realignment date.

Kindly Note: The District Athletic Committee has the authority to approve or reject any proposal.

School: _______________________________________________________________________ Anticipated Realignment: _________________________________________________________ Schools Impacted: ______________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ A. Attach Constitution for current League, highlighting realignment regulations. 1. Reason for realignment based on

Records over five (5) years within current league structure Records versus all proposed league schools Any school that does not have a 5-year record will use the data available Number of league changes made in the last five (5) years

37

2. Current School and League profile

League Profile School Profile Number of Students Geographical Location Longest Driving Distance Among All Schools Athletic Programs Offered

3. Affect upon natural/traditional rivalries – Thanksgiving Day Games, et al 4. Narrative

Rationale of school making this proposal How does this proposal impact the teams involved? How does this movement impact all league schools? Proposed scheduling formula. How does this movement impact the scheduling? Other

5. Attach the official Minutes reflecting required voted from all affected leagues. The District Athletic Committee will only act upon requests that include all the above required information. Signed: __________________________________________Date _________________________ Principal: (please print) ___________________________________________________________ Signed: ___________________________________________Date: _______________________ Athletic Director: (please print) _____________________________________________________ School: _______________________________________________________________________

** Please attach this sheet to your proposal. ** 3/10/2006

38

*SPORTSMANSHIP HANDSHAKE REPORT FORM

SPORT: ________________________________________________________ Boys Girls Varsity

1. Regular Season MIAA Tournament Section: North South Central West State

2.Site:___________________________________________________________________

Date: _______________________________________________________________________________________

School

(Visitors) Vs.

School

(Home)

EX GD FR PR Sportsmanship of Players EX GD FR PR

EX GD FR PR Sportsmanship of Coaches EX GD FR PR

EX GD FR PR Sportsmanship of Cheerleaders EX GD FR PR

EX GD FR PR Sportsmanship of Fans EX GD FR PR

Post-Game Handshake

Rationale for suspending Handshake:__________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

Name: _________________________________________________ Position __________________________________

Address: ____________________________________________________________________________ Date: _________

Email Address: ______________________________________________________________________________________

*Report Form completion is necessary only in event handshake is suspended. To be completed either by Site Manager or Contest Official responsible for the decision to suspend the handshake ceremony. This form should be submitted by the Site Manager within 24 hours to: MIAA Sportsmanship Committee 33 Forge Parkway Franklin, MA 02038 Fax: 508-541-9888

Posted 8/25/10 39

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